EP2389880B1 - Device for ligament repair - Google Patents
Device for ligament repair Download PDFInfo
- Publication number
- EP2389880B1 EP2389880B1 EP11178595A EP11178595A EP2389880B1 EP 2389880 B1 EP2389880 B1 EP 2389880B1 EP 11178595 A EP11178595 A EP 11178595A EP 11178595 A EP11178595 A EP 11178595A EP 2389880 B1 EP2389880 B1 EP 2389880B1
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- EP
- European Patent Office
- Prior art keywords
- guide
- drill
- guide member
- bone
- arm
- Prior art date
- Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
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Links
- 210000003041 ligament Anatomy 0.000 title claims description 32
- 230000008439 repair process Effects 0.000 title claims description 5
- 210000000988 bone and bone Anatomy 0.000 claims description 67
- 230000007246 mechanism Effects 0.000 claims description 9
- 238000000034 method Methods 0.000 description 30
- 210000002303 tibia Anatomy 0.000 description 24
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- 238000005553 drilling Methods 0.000 description 9
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- 210000003127 knee Anatomy 0.000 description 7
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- 210000004872 soft tissue Anatomy 0.000 description 3
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- 230000001054 cortical effect Effects 0.000 description 2
- 238000003780 insertion Methods 0.000 description 2
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Images
Classifications
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/56—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor
- A61B17/58—Surgical instruments or methods for treatment of bones or joints; Devices specially adapted therefor for osteosynthesis, e.g. bone plates, screws, setting implements or the like
- A61B17/88—Osteosynthesis instruments; Methods or means for implanting or extracting internal or external fixation devices
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/16—Bone cutting, breaking or removal means other than saws, e.g. Osteoclasts; Drills or chisels for bones; Trepans
- A61B17/17—Guides or aligning means for drills, mills, pins or wires
- A61B17/1714—Guides or aligning means for drills, mills, pins or wires for applying tendons or ligaments
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/16—Bone cutting, breaking or removal means other than saws, e.g. Osteoclasts; Drills or chisels for bones; Trepans
- A61B17/17—Guides or aligning means for drills, mills, pins or wires
- A61B17/1739—Guides or aligning means for drills, mills, pins or wires specially adapted for particular parts of the body
- A61B17/1764—Guides or aligning means for drills, mills, pins or wires specially adapted for particular parts of the body for the knee
Definitions
- the present invention generally relates to surgical methods and devices, and more particularly to instruments and methods for use in knee reconstruction to repair torn ligaments and procedures for such reconstructions.
- Tissue detachment may occur in many ways, e.g., as the result of an accident such as a fall, overexertion during a work-related activity, during the course of an athletic event, or in any one of many other situations and/or activities. These types of injuries are generally the result of excess stress or extraordinary forces being placed upon the tissues.
- the injury frequently heals without medical intervention, the patient rests, and care is taken not to expose the injury to undue strenuous activities during the healing process. If, however, the ligament or tendon is completely detached from its attachment site on an associated bone or bones, or if it is severed as the result of a traumatic injury, surgical intervention may be necessary to restore full function to the injured joint. A number of conventional surgical procedures exist for re-attaching such tendons and ligaments to bone.
- ACL anterior cruciate ligament
- a ligament graft with a bone graft on one of its ends is sized so as to fit within the bone tunnels.
- Suture is then attached to the bone graft and thereafter passed through the tibia and femoral bone tunnels.
- the bone graft is then pulled through the tibial tunnel and up into the femoral tunnel using the suture.
- the ligament graft ligament extends back out of the femoral tunnel, across the interior of the knee joint, and then through the tibial tunnel.
- the free end of the ligament graft ligament resides outside the tibia, at the anterior side of the tibia.
- a bone screw is inserted between the bone graft and the wall of femoral bone tunnel so as to securely lock the bone graft in position by a tight interference fit.
- the free end of the ligament graft ligament is securely attached to the tibia.
- aligned femoral and tibial tunnels are initially formed in a human knee.
- a bone graft with a ligament graft attached thereto is passed through the tunnels to a blind end of the femoral tunnel where the block is fixed in place by an anchor.
- the ligament extends out of the tibial tunnel, and the end is attached to the tibia cortex by staples or the like.
- the end of the ligament may be fixed in the tibial tunnel by an anchor or by an interference screw.
- Various types of ligament and/or suture anchors for attaching soft tissue to bone are also well known in the art. A number of these devices are described in detail in U.S. Pat. Nos. 4,898,156 , 4,899,743 , 4,968,315 , 5,356,413 , and 5,372,599 , all of which are commonly assigned to Mitek Surgical Products, Inc., a Johnson & Johnson company.
- an ACL reconstruction procedure may be performed where instead of reconstructing the dual bundle structure of the native ACL with the functional equivalent of a single band graft, two bone grafts can be used, each graft in an individual bone tunnel.
- Such an "anatomic" or double-tunnel procedure traditionally involves freehandedly positioning the two tunnels in the tibia and femur. Forming the two tunnels in the correct positions can be technically challenging, time consuming, and have little consistency or reproducibility in tunnel placement from patient to patient.
- FR 2552655 on wich the preamble of claim 1 is based discusses a surgical device comprising a probe for insertion into soft tissue during a surgical operation, and a drill guide for guiding a drill in the operation.
- the guide is connection to the probe and is adjustable in position and attitude relative thereto.
- the guide is releasably lockable in a plurality of positions.
- a surgical drill guide apparatus having a first guide member with a first longitudinal guide passage adapted to receive a drill guide pin therein to form a bone tunnel.
- a first support arm is coupled to and extends horizontally from the first guide member.
- the first support arm can be fixedly mated to the first guide member.
- the first support arm has at least one arcuate section.
- the apparatus includes a second guide member having a second longitudinal guide passage adapted to receive a drill guide pin to form a bone tunnel.
- the second guide member is slidably disposed along the at least one arcuate section of the first support arm to form a variable angle relative to the first guide member.
- the second guide member can also include a locking element adapted to lock the second guide member in a position on the at least one arcuate section.
- the first and second guide members each have a longitudinal axis, and the axes do not intersect.
- the apparatus can also include a first drill guide mounted in the first longitudinal guide passage and a second drill guide mounted in the second longitudinal guide passage.
- the apparatus includes a second support arm coupled to and extending vertically from the first guide member, and an engagement member slidably mounted to the second support arm.
- the second support arm can be fixedly mated to the first guide member, and it can have at least one arcuate portion.
- the engagement member has a distal tip adapted to indicate an exit location of bone tunnels formed by drill bits disposed through the first and second guide members.
- the present invention generally provides devices for repairing ligaments and for positioning and forming bone tunnels.
- the various methods and devices disclosed herein can be used in a variety of surgical procedures, however the methods and devices are particularly useful for repairing an anterior cruciate ligament ("ACL") in a human knee.
- ACL anterior cruciate ligament
- the torn ACL can be replaced with two ligament grafts which are each anchored to the tibia and femur.
- the term "ligament graft,” as used herein, is intended to include natural materials, such as autografts, allografts, and xenografts, including harvested ligaments and tendons, as well as synthetic materials.
- a ligament graft can also include an anchoring element attached thereto for anchoring the graft to the tibia and femur.
- the ligament graft can include a bone graft, plug, or other member, attached to one or both terminal ends thereof.
- a person skilled in the art will appreciate that the various methods and devices disclosed herein can be used in a variety of surgical procedures, and that the particular configuration of the ligament grafts can vary depending on the intended use, and virtually any ligament grafts known in the art can be used with the devices and methods disclosed herein.
- FIG. 1 illustrates one exemplary embodiment of a surgical drill guide instrument 60.
- the instrument 60 allows for placement of multiple tibial tunnels.
- the instrument 60 generally includes first and second guide members 12, 30 connected together via a support or outrigger arm 26.
- the guide members 12, 30 can be angularly adjustable relative to one another to form an angle A1 therebetween that defines an insertion trajectory of two bone tunnels to be formed.
- the instrument 60 can also include first and second guide pin sleeves or drill guides 40a, 40b slidably disposable through guide channels 13, 31 formed in the guide members 12, 30.
- the drill guides 40a, 40b can be configured to receive drill bits therethrough for drilling bone tunnels in bone.
- FIG. 1 illustrates one exemplary embodiment of a surgical drill guide instrument 60.
- the instrument 60 allows for placement of multiple tibial tunnels.
- the instrument 60 generally includes first and second guide members 12, 30 connected together via a support or outrigger arm 26.
- the guide members 12, 30 can be angularly adjustable relative to one another to form
- the instrument 60 can also optionally include a tibial engagement member 17 that is coupled to one of the guide members, e.g., the first guide member 12, and that is adapted to engage a tibial plateau to indicate an exit location of the first and second bone tunnels.
- the instrument 60 can allow for adjustable placement of tunnel entrance points on the tibial cortex and for adjustable offset of tunnel exit points on the tibial plateau. The placement and offset can also be recorded using the instrument 60, thereby allowing time-saving reproduction of multiple tunnels.
- the guide members 12, 30 can each have a variety of configurations, but in the illustrated embodiment each guide member 12, 30 generally includes a housing and a pathway.
- the housings and the pathways can have a variety of shapes, but they are preferably configured to receive a drill guide or other drilling apparatus.
- each housing is generally rectangular and each pathway 13, 31 is generally cylindrical for slidably receiving a generally cylindrical drill guides 40a, 40b, as will be discussed further below.
- the guide members 12, 30 can each also include a locking mechanism for locking the drill guides 40a, 40b in position within the guide members 12, 30.
- each locking mechanisms is in the form of a conventional ratchet having a pawl that engages teeth formed on the guide members.
- a person skilled in the art will appreciate that a variety of other locking mechanisms known in the art can be used to allow the guide members to be locked in a fixed positioned relative to the guide members 12, 30.
- Each of the guide members 12, 30 can also be angularly adjustable relative to one another. While various techniques can be used for allowing angular adjustability, in an exemplary embodiment, as shown, the guide members 12, 30 are coupled to one another via the support or outrigger arm 26.
- the outrigger arm 26 can be a generally elongate member, and in an exemplary embodiment all, or at least a portion of, the elongate member is arcuate.
- the outrigger arm 26 can be movably coupled to the first and second guide members 12, 30, or one of the guide members 12, 30 can be fixed relative to the outrigger arm 26 while the other guide member 12, 30 is movable.
- the outrigger arm 26 is mated to the first guide member 12 in a transverse, keyed thru-hole 12b located in the side of the first guide member 12 such that the outrigger arm 26 can extend horizontally from the first guide member 12.
- the outrigger arm 26 is fixedly mated to the first guide member 12 and secured via a thumbscrew 22. In other embodiments, however, the outrigger arm 26 can be rotatably, but non-slidably mated to the first guide member 12.
- the outrigger arm 26 can slidably couple to the second guide member 30 in a slot 30a formed in the second guide member 30.
- the slot 30a can have virtually any configuration, and in this embodiment it is a generally rectangular arcuate channel that can removably seat the arcuate outrigger arm 26.
- the second guide member 30 can thus slidably move along the outrigger arm 26 until positioned at a desired angle A1 relative to the first guide member 12. Once positioned as desired, the second guide member 30 can be secured in position using a conventional locking mechanism, such as a thumbscrew 32.
- the outrigger arm 26 can optionally include external markings 28 that indicate the angle A1 between the first and second guide members 12, 30.
- the outrigger arm 26 can be oriented in a vertical direction about an axis AX1 relative to the first guide member 12 to achieve an offset between the longitudinal axes 13a, 31 a of the guide channels 13, 31 and hence the drill guide channels 41a, 41b and bone tunnels that may be drilled following them.
- the instrument 60 can include multiple outrigger arms (each similar to the outrigger arm 26) that can be keyed to different rotational positions within the slotted thru-hole 12b on the first guide member 12.
- the multiple outriggers can be keyed with a series of slot patterns to maintain the ability to use a single outrigger with a given offset on both the left and right side of the first guide member 12, or individual left and right outrigger arms can be constructed for each desired offset position.
- the multiple outrigger arms could be fixed in position within the thru-hole 12b.
- a locking mechanism such as the thumbscrew 22 as shown, can optionally be used.
- the outrigger arm 26 can be rotatably but non-slidably mated to the first guide member 12.
- the offset of the outrigger arm 26 can be adjusted (i.e., either rotationally or by selecting an outrigger arm having a predetermined offset) and secured following advancement of the first guide pin 50a through the drill guide 40a (and prior to advancement of a second guide pin 50b, described further below) to help visually gauge a desired offset, or the offset is adjusted and secured at any point prior to placement of the guide pin 50a in the guide sleeve 40a.
- An additional guide pin positioned through a hole 20 in the outrigger arm 26 can be used as an offset positional reference and/or to provide additional support to the outrigger arm 26, as further described below.
- FIG. 1 shows the outrigger arm 26 on a right side of the first guide member 12, but the outrigger arm 26 can be located on a left side of the first guide member 12, as shown in another embodiment of an instrument 60' in FIG. 2 .
- the instruments 60, 60' are configured to accommodate the anatomies of the left and right knees, respectively.
- each drill guide 40a, 40b has a generally elongate tubular configuration, such as a cylindrical shape for receipt in the cylindrical guide channels 13, 31, as shown. This will allow the drill guides 40a, 40b to guide drill bits or any other bone drilling devices disposed in the drill guides 40a, 40b through the guide members 12, 30 and into bone.
- the drill bits or other bone drilling devices may be directly disposed in the guide channels 13, 31 without the drill guides 40a, 40b.
- the first drill guide 40a has external markings 46 at its proximal end 48, external teeth 45 or other surface features at its mid-portion or adjacent to its distal end 53, and a center channel 41 a extending therethrough between the proximal and distal ends 48, 53 thereof.
- the first drill guide 40a can be disposed in the first guide member 12 through the channel 13, parallel to the first drill guide's channel 41a.
- the teeth 45 can be engaged by a locking mechanism within the channel 13 to allow movement of the first sleeve 40a in a forward or distal direction between a plurality of fixed positions.
- the first sleeve 40a can also include a bone-engaging distal end, such as teeth 44 formed thereon that engage bone at a desired bone tunnel entrance location, as described further below.
- the external markings 46 on the first drill guide 40a can indicate an estimated depth of the tunnel with, for example, depth lines printed, embossed, etched, or otherwise marked on the first drill guide 40a that can advance into the channel 13 with the sleeve 40a.
- the first drill guide 40a can also include a first annular knob handle 49 mounted or otherwise coupled to the proximal end 48 of the first drill guide 40a for grasping the drill guide 40a and facilitating movement relative to the guide channel 13.
- the knob handle 49 can include an opening 49a through which a tool or device can be inserted to turn or otherwise manipulate the handle 49 to distally advance the sleeve 40a.
- the second guide pin sleeve or drill guide 40b can be configured and manipulated similar to the first drill guide 40a and it can include external markings 46b at its proximal end 48b, external teeth 45b or other surface features at its mid-portion or adjacent to its distal end 42, a center channel 41b, and a knob handle 49b having an opening 49c.
- the second drill guide 40b is typically disposed in and advanced through the second guide member 30 after the first drill guide 40a has been disposed in and advanced through the first guide member 12, but the drill guides 40a, 40b can be disposed in and advanced through the guide members 12, 30 in any order.
- the device 60 can also optionally include a tibial engagement member 17 that is effective to engage the tibial plateau and indicate an exit location for guide pins 50a, 50b (and/or other devices used to form the bone tunnels) disposed through the drill guides 40a, 40b.
- the tibial engagement member 17 can have a variety of configurations, but in the illustrated embodiment it include a slider arm 16 and a probe arm 10.
- the slider arm 16 can be arcuate or straight and it can include a plurality of connected, angulated straight and/or curved segments. In this embodiment, the slider arm 16 has a generally arcuate orientation extending vertically from the first guide member 12, i.e., offset 45° from the outrigger arm 26.
- the slider arm 16 can, however, have an arcuate portion and a straight portion, or any other orientation.
- the probe arm 10 generally includes an elongate body that can be adjustably or slidably mounted to the slider arm 16 through a passage 11 a formed in a handle portion 11 of the probe arm 10.
- the probe arm 10 can also include a distally extending arm portion 10a including a distal tip 18.
- the distal tip 18 is preferably angulated proximally (e.g., toward a direction of an approaching guide pin), but it can have a distal orientation, both proximal and distal angulations, or neither proximal and distal orientations.
- a position of the probe arm 10, and hence the distal tip 18 and desired endpoint of a bone tunnel, can be slidably adjusted on the slider arm 16 to form an angle A2 between the arm portion 10a of the probe arm 10 and the first guide pin 50a (and the first drill guide 40a).
- FIG. 3 shows the slider arm 16 slidably mounted to the probe arm 10.
- External markings 54 on the slider arm 16, which can be printed, embossed, etched, or otherwise marked on the slider arm 16, can indicate the A2 angular position of the probe arm 10.
- the probe arm 10 can be fixed in position to form a desired angle A2 by, for example, using a conventional locking mechanism such as a thumbscrew 14 coupled to the handle portion 11 of the probe arm 10 and adapted to engage the slider arm 16.
- the probe arm 10 is typically adjusted to a desired position on the slider arm 16 prior to advancing the guide pin 50a through bone, although the probe arm 10 can be adjusted at any point or points during a ligament repair procedure.
- FIG. 1 also illustrates first and second drill tipper guide pins 50a, 50b which can be used with the guide device 60.
- the first drill tipped guide pin 50a can be disposed through the center channel 41 a of the first guide sleeve 40a and advanced distally beyond the teeth 44 of the first guide sleeve 40a and toward the distal tip 18 of the probe arm 10.
- the first guide pin 50a can be advanced in any known manner, for example, by coupling the guide pin 50a to a conventional surgical drill or driver and advancing the guide pin 50a through the first drill guide 40a and into bone.
- the guide pin 50a can be advanced through bone, as further described below, until a distal tip 51a of the guide pin 50a is proximate to the tip 18 of the probe arm 10.
- the drill guide pin 50a can be removed from the drill chuck of the surgical drill and left in place. Similar to that described above regarding the first guide pin 50a, the second guide pin 50b can be advanced through the second drill guide 40b with its distal tip 51 c approaching the distal tip 18 of the probe arm 10.
- guide pins 50a, 50b are merely shown for example.
- FIG. 4 illustrates one exemplary method for forming bone tunnels for ligament grafts in a surgical procedure, and in particular dual tibial tunnels of a human knee in an arthroscopic procedure.
- the first guide member 12 can be positioned adjacent to a bone, e.g., the tibia 100, such that the first guide member 12 can aim the first guide pin 50a through the tibia 100 along a first pathway, e.g., the first longitudinal axis 13a extending through the first guide member 12 and the first drill guide 40a.
- Positioning the first guide member 12 can include inserting the distal portion 10a of the probe arm 10 through an arthroscopic portal (although the instrument 60 can also be used in an open procedure) and orienting it such that the distal tip 18 of the probe arm 10 can engage a section of a tibial plateau 110 of the tibia 100 at an intended tibial tunnel exit point.
- the first drill guide 40a can be advanced until the guide sleeve distal teeth 44 engage the cortical bone of the tibia 100 at a desired tibial tunnel entrance location 122.
- the drill-tipped guide pin 50a can be inserted through the center channel 41 of the first guide pin sleeve 40a, mounted to a conventional surgical drill driver, and advanced through the tibial bone 100 using the surgical drill/driver so that the tip 51 a of the pin 50a is proximate to the tip 18 of the probe arm 10 on the tibial plateau 110 and indicates intended tunnel depth.
- the first guide pin 50a can be inserted through the first guide member 12 at any point during the procedure, but it is typically inserted after the first guide member 12 has been positioned at the tibia 100 and before the second guide member 30 has been positioned at the tibia 100.
- the second guide member 30 can be positioned adjacent to the tibia 100. Positioning the second guide member 30 can include inserting the outrigger arm 26 through the thru-hole 12b of the first guide member 12. Adjustment of the location of the second guide member 30 on the outrigger arm 26 determines the relative positions of the tibial tunnel entrance points to one another, while the vertical offset of the outrigger arm 26 determines the relative vertical offset of the tibial tunnel entrance points. A rotational position of the outrigger arm 26 about the axis AX1 can be adjusted to orient the vertical offset between the two tibial tunnels.
- an additional guide pin 21 has been inserted through a thru-hole 20 in the outrigger arm 26 at a 45° angle position on the outrigger arm 26 to act as a position reference with respect to the tibial crest and to help correctly determine the offset.
- the outrigger arm 26 can be secured in position using the thumbscrew 22. If the second guide member 30 is not already secured to the outrigger arm 26, it can be secured to the outrigger arm 26 at the desired angle A1 relative to the first guide member 12.
- the second guide member 30 can be slidably moved along outrigger arm 26 toward and away from the first guide member 12 to adjust the A1 angular orientation of the second guide member 30 relative to the first guide member 12, and once positioned as desired it can be tightened and locked in position using the thumbscrew 32.
- the second drill guide 49b and the second guide pin 50b can be inserted and advanced through the second guide member 30 as discussed above.
- the instrument 60 can be completely assembled prior to deployment and tibial engagement, the order of drilling the tunnels may be varied, the sleeves 40a, 40b may be removed after drilling with pins 50a and 50b or left in place, etc.
- the instrument 60 can be disengaged from the bone 100.
- Both of the ratcheted guide pin sleeves 40a, 40b can be rotated 180° to disengage the locking mechanism in the guide members 12, 30 so that the sleeves 40a, 40b can be withdrawn from their respective guide members 12, 30.
- the outrigger arm 26 can be removed from the first guide member 12 by releasing the thumbscrew 22 and withdrawing the still assembled outrigger 26 and the second guide member 30 over the guide pin 50b.
- the first guide member 12, along with the attached slider arm 16 and probe arm 10, can be withdrawn over the guide pin 50a, leaving the two guide pins 50a, 50b placed in the tibial bone 100 along intended tibial tunnel trajectories having respective tibial tunnel exit points 106, 108 as shown in FIG 5 .
- FIG. 5 illustrates 5mm tunnels having a 3mm offset, although any offset and any size reamers can be used.
- FIG. 6 shows, by way of non-limiting example, a variety of possible tunnel offset positions using either a 5mm or 8mm reamer.
- a kit is provided containing a plurality of outrigger arms, each having a predetermined offset that corresponds to the tunnel offset positions shown in FIG. 6 .
- FIG. 7 illustrates a cross-section of FIG. 3 , looking toward the probe arm 10.
- a distance D can separate the guide pins 50a, 50b, and the distance D can vary based on the offset of the outrigger arm 26 and the position of the second guide member 30 on the outrigger arm 26.
- the tunnels can each maintain a substantially constant diameter through the entire length thereof, thereby ensuring that the grafts disposed therein will have sufficient freedom to move without impingement by the tunnels.
- the offset and the distance D are preferably set to prevent intersection of the axes, the instrument 60 enables a surgeon to allow intersection, such as if the offset is slight enough or is nonexistent. In such a case, it may be advisable for easier maneuverability to slightly withdraw the second guide pin wire 50b prior to reaming the tunnel over the first guide pin wire 50a.
- first and second tibial tunnels 120, 130 that meet with an offset at the tibial plateau 110 as shown in FIGS. 8-9 .
- the first and second tunnels 120, 130 form, respectively, first and second passageways 128, 138 that extend between first and second entrance openings 122, 132 and first and second exit openings 125, 135.
- tibial tunnels 120, 130 are in place, completion of a dual bundle ACL reconstruction can be performed based on individual surgeon preference.
- two femoral tunnels can be created in a femur 200.
- a currently available conventional femoral offset guide can be used through one of the tibial tunnels 120, 130 to locate a guide pin at the appropriate anatomic position within the femoral notch.
- a conventional cannulated acorn reamer can be used to create a femoral tunnel of the appropriate depth.
- a second guide pin, placed either through the second tibial tunnel 130 or an auxiliary arthroscopic portal can be positioned adjacent to the first femoral tunnel location and a tunnel drilled to the appropriate depth in the same manner as the first.
- Graft bundles can next be passed through the tibial tunnels 120, 130 into the femoral tunnels in a conventional manner.
- a guide pin with an eyelet can be re-introduced through one of the tibial tunnels 120, 130 into the corresponding femoral tunnel and extended along the tunnel axis until the guide pin tip extended through the distal tissue of the lateral thigh.
- One of the graft bundles can be doubled over a passing suture, the suture can be threaded through the eyelet of the guide pin, and the guide pin can be pulled until the passing suture exited from the skin on the thigh.
- the passing suture would be used to pull the graft through the tibial tunnel 120, 130 into the femoral tunnel until appropriately seated.
- the second graft bundle can be passed and seated in the same manner as the first.
- a second guide pin can be reintroduced through the auxiliary portal and an intermediate step of capturing an attached passing loop with a crochet hook or suture grasper inserted through the tibial tunnel 120, 130 and pulling the loop though the tunnel in a retrograde fashion would be required prior to proceeding with passing the second bundle of the graft in the manner described above.
- Fixation of the graft in the tibial and femoral tunnels can be accomplished using any of a variety of conventional fixation methods/devices, including but not limited to interference screws, cross pins, sheaths with compression screws, and cortical buttons, posts and screws.
- One method for anchoring bone grafts in bone tunnels is through a "cross-pinning" technique in which a pin, screw, or rod is driven into the bone transversely to the bone tunnel so as to intersect the bone graft and thereby cross-pin the bone graft in the bone tunnel.
- a drill guide is generally used.
- the drill guide can ensure that the transverse passage is positioned in the bone so that it will intersect the appropriate tunnel section and the bone graft.
- the femoral bundles of the graft can be fixed first using the chosen femoral fixation method.
- the knee can then be flexed to an appropriate position and the bundles can be tensioned to an appropriate amount prior to placement of the tibial fixation devices.
- each of the graft bundles may be tensioned and fixed at different flexion positions and tension levels during the procedure.
- biocompatible materials include, by way of non-limiting example, composite plastic materials, biocompatible metals and alloys such as stainless steel, titanium, titanium alloys and cobalt-chromium alloys, and any other material that is biologically compatible and non-toxic to the human body.
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Description
- The present invention generally relates to surgical methods and devices, and more particularly to instruments and methods for use in knee reconstruction to repair torn ligaments and procedures for such reconstructions.
- Joint injuries may commonly result in the complete or partial detachment of ligaments, tendons and soft tissues from bone. Tissue detachment may occur in many ways, e.g., as the result of an accident such as a fall, overexertion during a work-related activity, during the course of an athletic event, or in any one of many other situations and/or activities. These types of injuries are generally the result of excess stress or extraordinary forces being placed upon the tissues.
- In the case of a partial detachment, commonly referred to under the general term "sprain," the injury frequently heals without medical intervention, the patient rests, and care is taken not to expose the injury to undue strenuous activities during the healing process. If, however, the ligament or tendon is completely detached from its attachment site on an associated bone or bones, or if it is severed as the result of a traumatic injury, surgical intervention may be necessary to restore full function to the injured joint. A number of conventional surgical procedures exist for re-attaching such tendons and ligaments to bone.
- One such procedure involves the re-attachment of the detached tissue using "traditional" attachment devices such as staples, sutures, and bone screws. Such traditional attachment devices have also been used to attach tendon or ligament grafts (often formed from autologous tissue harvested from elsewhere in the body) to the desired bone or bones. In one procedure, a damaged anterior cruciate ligament ("ACL") is replaced in a human knee. Initially, bone tunnels are formed through the tibia and femur at the points of normal attachment of the ACL. Next, a ligament graft with a bone graft on one of its ends is sized so as to fit within the bone tunnels. Suture is then attached to the bone graft and thereafter passed through the tibia and femoral bone tunnels. The bone graft is then pulled through the tibial tunnel and up into the femoral tunnel using the suture. As this is done, the ligament graft ligament extends back out of the femoral tunnel, across the interior of the knee joint, and then through the tibial tunnel. The free end of the ligament graft ligament resides outside the tibia, at the anterior side of the tibia. Next, a bone screw is inserted between the bone graft and the wall of femoral bone tunnel so as to securely lock the bone graft in position by a tight interference fit. Finally, the free end of the ligament graft ligament is securely attached to the tibia.
- In another ACL reconstruction procedure, aligned femoral and tibial tunnels are initially formed in a human knee. A bone graft with a ligament graft attached thereto is passed through the tunnels to a blind end of the femoral tunnel where the block is fixed in place by an anchor. The ligament extends out of the tibial tunnel, and the end is attached to the tibia cortex by staples or the like. Alternatively, the end of the ligament may be fixed in the tibial tunnel by an anchor or by an interference screw. Various types of ligament and/or suture anchors for attaching soft tissue to bone are also well known in the art. A number of these devices are described in detail in
U.S. Pat. Nos. 4,898,156 ,4,899,743 ,4,968,315 ,5,356,413 , and5,372,599 , all of which are commonly assigned to Mitek Surgical Products, Inc., a Johnson & Johnson company. - Alternatively, an ACL reconstruction procedure may be performed where instead of reconstructing the dual bundle structure of the native ACL with the functional equivalent of a single band graft, two bone grafts can be used, each graft in an individual bone tunnel. Such an "anatomic" or double-tunnel procedure traditionally involves freehandedly positioning the two tunnels in the tibia and femur. Forming the two tunnels in the correct positions can be technically challenging, time consuming, and have little consistency or reproducibility in tunnel placement from patient to patient.
- Accordingly, there is a need for improved methods and devices for repairing ligaments and for positioning and forming bone tunnels.
-
FR 2552655 - In an embodiment, a surgical drill guide apparatus is provided having a first guide member with a first longitudinal guide passage adapted to receive a drill guide pin therein to form a bone tunnel. A first support arm is coupled to and extends horizontally from the first guide member. In one embodiment, the first support arm can be fixedly mated to the first guide member. The first support arm has at least one arcuate section. The apparatus includes a second guide member having a second longitudinal guide passage adapted to receive a drill guide pin to form a bone tunnel. The second guide member is slidably disposed along the at least one arcuate section of the first support arm to form a variable angle relative to the first guide member. The second guide member can also include a locking element adapted to lock the second guide member in a position on the at least one arcuate section. In some embodiments, the first and second guide members each have a longitudinal axis, and the axes do not intersect. The apparatus can also include a first drill guide mounted in the first longitudinal guide passage and a second drill guide mounted in the second longitudinal guide passage. The apparatus includes a second support arm coupled to and extending vertically from the first guide member, and an engagement member slidably mounted to the second support arm. The second support arm can be fixedly mated to the first guide member, and it can have at least one arcuate portion. In one exemplary embodiment, the engagement member has a distal tip adapted to indicate an exit location of bone tunnels formed by drill bits disposed through the first and second guide members.
- The invention will be more fully understood from the following detailed description taken in conjunction with the accompanying drawings, in which:
-
FIG. 1 is a perspective view of one exemplary embodiment of an instrument useful in drilling tunnels in bone in a ligament reconstruction procedure; -
FIG. 2 is a perspective view of another exemplary embodiment of an instrument useful in drilling tunnels in bone in a ligament reconstruction procedure; -
FIG. 3 is a perspective side view of the instrument ofFIG. 1 ; -
FIG. 4 is a perspective view of the instrument ofFIG. 1 engaging an upper end of a tibia and showing a tip of the instrument's probe arm engaging a tibial plateau; -
FIG. 5 is top view of the tibia ofFIG. 4 showing drill tips exiting an upper end of the tibia; -
FIG. 6 is a table showing various tunnel offsets using various sized drill guides with the instrument ofFIG. 1 ; -
FIG. 7 is a cross-sectional schematic view of a portion of the instrument ofFIG. 1 ; -
FIG. 8 is a side view of the tibia ofFIG. 4 showing entrance holes of dual tunnels drilled in an upper section of the tibia; -
FIG. 9 is a schematic illustration of entrances to tunnels drilled in the tibia ofFIG. 4 , exits from the tunnels, tunnel trajectories, and a footprint in the tibial plateau; and -
FIG. 10 is a perspective view of the instrument ofFIG. 1 engaging the tibia ofFIG. 4 and a femur. - Certain exemplary embodiments will now be described to provide an overall understanding of the principles of the structure, function, manufacture, and use of the devices and methods disclosed herein. One or more examples of these embodiments are illustrated in the accompanying drawings. Those skilled in the art will understand that the devices specifically described herein and illustrated in the accompanying drawings are non-limiting exemplary embodiments and that the scope is defined solely by the claims. The features illustrated or described in connection with one exemplary embodiment may be combined with the features of other embodiments. Such modifications and variations are intended to be included within the scope of the present application.
- The present invention generally provides devices for repairing ligaments and for positioning and forming bone tunnels. The various methods and devices disclosed herein can be used in a variety of surgical procedures, however the methods and devices are particularly useful for repairing an anterior cruciate ligament ("ACL") in a human knee. In an ACL repair, the torn ACL can be replaced with two ligament grafts which are each anchored to the tibia and femur. The term "ligament graft," as used herein, is intended to include natural materials, such as autografts, allografts, and xenografts, including harvested ligaments and tendons, as well as synthetic materials. A ligament graft can also include an anchoring element attached thereto for anchoring the graft to the tibia and femur. For example, the ligament graft can include a bone graft, plug, or other member, attached to one or both terminal ends thereof. The term "bone graft," as used herein, in intended to include natural materials, such as autografts, allografts, and xenografts, as well as synthetic materials. A person skilled in the art will appreciate that the various methods and devices disclosed herein can be used in a variety of surgical procedures, and that the particular configuration of the ligament grafts can vary depending on the intended use, and virtually any ligament grafts known in the art can be used with the devices and methods disclosed herein.
-
FIG. 1 illustrates one exemplary embodiment of a surgicaldrill guide instrument 60. In general, theinstrument 60 allows for placement of multiple tibial tunnels. As shown, theinstrument 60 generally includes first andsecond guide members outrigger arm 26. Theguide members instrument 60 can also include first and second guide pin sleeves ordrill guides guide channels guide members FIG. 1 , theinstrument 60 can also optionally include atibial engagement member 17 that is coupled to one of the guide members, e.g., thefirst guide member 12, and that is adapted to engage a tibial plateau to indicate an exit location of the first and second bone tunnels. In use, theinstrument 60 can allow for adjustable placement of tunnel entrance points on the tibial cortex and for adjustable offset of tunnel exit points on the tibial plateau. The placement and offset can also be recorded using theinstrument 60, thereby allowing time-saving reproduction of multiple tunnels. - The
guide members guide member pathway guide members guide members guide members - Each of the
guide members guide members outrigger arm 26. Theoutrigger arm 26 can be a generally elongate member, and in an exemplary embodiment all, or at least a portion of, the elongate member is arcuate. Theoutrigger arm 26 can be movably coupled to the first andsecond guide members guide members outrigger arm 26 while theother guide member outrigger arm 26 is mated to thefirst guide member 12 in a transverse, keyed thru-hole 12b located in the side of thefirst guide member 12 such that theoutrigger arm 26 can extend horizontally from thefirst guide member 12. Preferably, theoutrigger arm 26 is fixedly mated to thefirst guide member 12 and secured via athumbscrew 22. In other embodiments, however, theoutrigger arm 26 can be rotatably, but non-slidably mated to thefirst guide member 12. - The
outrigger arm 26 can slidably couple to thesecond guide member 30 in aslot 30a formed in thesecond guide member 30. Theslot 30a can have virtually any configuration, and in this embodiment it is a generally rectangular arcuate channel that can removably seat thearcuate outrigger arm 26. Thesecond guide member 30 can thus slidably move along theoutrigger arm 26 until positioned at a desired angle A1 relative to thefirst guide member 12. Once positioned as desired, thesecond guide member 30 can be secured in position using a conventional locking mechanism, such as a thumbscrew 32. As further shown inFIG. 1 , theoutrigger arm 26 can optionally includeexternal markings 28 that indicate the angle A1 between the first andsecond guide members - As indicated above, the
outrigger arm 26 can be oriented in a vertical direction about an axis AX1 relative to thefirst guide member 12 to achieve an offset between thelongitudinal axes 13a, 31 a of theguide channels drill guide channels instrument 60 can include multiple outrigger arms (each similar to the outrigger arm 26) that can be keyed to different rotational positions within the slotted thru-hole 12b on thefirst guide member 12. The multiple outriggers can be keyed with a series of slot patterns to maintain the ability to use a single outrigger with a given offset on both the left and right side of thefirst guide member 12, or individual left and right outrigger arms can be constructed for each desired offset position. The multiple outrigger arms could be fixed in position within the thru-hole 12b. A locking mechanism, such as thethumbscrew 22 as shown, can optionally be used. In other embodiments, as previously explained, theoutrigger arm 26 can be rotatably but non-slidably mated to thefirst guide member 12. The offset of theoutrigger arm 26 can be adjusted (i.e., either rotationally or by selecting an outrigger arm having a predetermined offset) and secured following advancement of thefirst guide pin 50a through thedrill guide 40a (and prior to advancement of asecond guide pin 50b, described further below) to help visually gauge a desired offset, or the offset is adjusted and secured at any point prior to placement of theguide pin 50a in theguide sleeve 40a. An additional guide pin positioned through ahole 20 in theoutrigger arm 26 can be used as an offset positional reference and/or to provide additional support to theoutrigger arm 26, as further described below. -
FIG. 1 shows theoutrigger arm 26 on a right side of thefirst guide member 12, but theoutrigger arm 26 can be located on a left side of thefirst guide member 12, as shown in another embodiment of an instrument 60' inFIG. 2 . Theinstruments 60, 60' are configured to accommodate the anatomies of the left and right knees, respectively. - Referring still to
FIG. 1 , the first and second drill guides 40a, 40b that are disposable through theguide channels guide members drill guide cylindrical guide channels guide members guide channels first drill guide 40a hasexternal markings 46 at itsproximal end 48,external teeth 45 or other surface features at its mid-portion or adjacent to itsdistal end 53, and acenter channel 41 a extending therethrough between the proximal and distal ends 48, 53 thereof. Thefirst drill guide 40a can be disposed in thefirst guide member 12 through thechannel 13, parallel to the first drill guide'schannel 41a. As mentioned above, theteeth 45 can be engaged by a locking mechanism within thechannel 13 to allow movement of thefirst sleeve 40a in a forward or distal direction between a plurality of fixed positions. Thefirst sleeve 40a can also include a bone-engaging distal end, such asteeth 44 formed thereon that engage bone at a desired bone tunnel entrance location, as described further below. Theexternal markings 46 on thefirst drill guide 40a can indicate an estimated depth of the tunnel with, for example, depth lines printed, embossed, etched, or otherwise marked on thefirst drill guide 40a that can advance into thechannel 13 with thesleeve 40a. As further shown inFIG. 1 , thefirst drill guide 40a can also include a first annular knob handle 49 mounted or otherwise coupled to theproximal end 48 of thefirst drill guide 40a for grasping thedrill guide 40a and facilitating movement relative to theguide channel 13. The knob handle 49 can include anopening 49a through which a tool or device can be inserted to turn or otherwise manipulate thehandle 49 to distally advance thesleeve 40a. - The second guide pin sleeve or
drill guide 40b can be configured and manipulated similar to thefirst drill guide 40a and it can includeexternal markings 46b at itsproximal end 48b,external teeth 45b or other surface features at its mid-portion or adjacent to itsdistal end 42, acenter channel 41b, and aknob handle 49b having anopening 49c. Thesecond drill guide 40b is typically disposed in and advanced through thesecond guide member 30 after thefirst drill guide 40a has been disposed in and advanced through thefirst guide member 12, but the drill guides 40a, 40b can be disposed in and advanced through theguide members - As previously indicated, the
device 60 can also optionally include atibial engagement member 17 that is effective to engage the tibial plateau and indicate an exit location forguide pins tibial engagement member 17 can have a variety of configurations, but in the illustrated embodiment it include aslider arm 16 and aprobe arm 10. Theslider arm 16 can be arcuate or straight and it can include a plurality of connected, angulated straight and/or curved segments. In this embodiment, theslider arm 16 has a generally arcuate orientation extending vertically from thefirst guide member 12, i.e., offset 45° from theoutrigger arm 26. Theslider arm 16 can, however, have an arcuate portion and a straight portion, or any other orientation. Theprobe arm 10 generally includes an elongate body that can be adjustably or slidably mounted to theslider arm 16 through apassage 11 a formed in ahandle portion 11 of theprobe arm 10. Theprobe arm 10 can also include a distally extendingarm portion 10a including adistal tip 18. Thedistal tip 18 is preferably angulated proximally (e.g., toward a direction of an approaching guide pin), but it can have a distal orientation, both proximal and distal angulations, or neither proximal and distal orientations. - A position of the
probe arm 10, and hence thedistal tip 18 and desired endpoint of a bone tunnel, can be slidably adjusted on theslider arm 16 to form an angle A2 between thearm portion 10a of theprobe arm 10 and thefirst guide pin 50a (and thefirst drill guide 40a).FIG. 3 shows theslider arm 16 slidably mounted to theprobe arm 10. External markings 54 on theslider arm 16, which can be printed, embossed, etched, or otherwise marked on theslider arm 16, can indicate the A2 angular position of theprobe arm 10. Theprobe arm 10 can be fixed in position to form a desired angle A2 by, for example, using a conventional locking mechanism such as athumbscrew 14 coupled to thehandle portion 11 of theprobe arm 10 and adapted to engage theslider arm 16. Theprobe arm 10 is typically adjusted to a desired position on theslider arm 16 prior to advancing theguide pin 50a through bone, although theprobe arm 10 can be adjusted at any point or points during a ligament repair procedure. -
FIG. 1 also illustrates first and second drill tipper guide pins 50a, 50b which can be used with theguide device 60. The first drill tippedguide pin 50a can be disposed through thecenter channel 41 a of thefirst guide sleeve 40a and advanced distally beyond theteeth 44 of thefirst guide sleeve 40a and toward thedistal tip 18 of theprobe arm 10. Thefirst guide pin 50a can be advanced in any known manner, for example, by coupling theguide pin 50a to a conventional surgical drill or driver and advancing theguide pin 50a through thefirst drill guide 40a and into bone. Theguide pin 50a can be advanced through bone, as further described below, until adistal tip 51a of theguide pin 50a is proximate to thetip 18 of theprobe arm 10. Thedrill guide pin 50a can be removed from the drill chuck of the surgical drill and left in place. Similar to that described above regarding thefirst guide pin 50a, thesecond guide pin 50b can be advanced through thesecond drill guide 40b with itsdistal tip 51 c approaching thedistal tip 18 of theprobe arm 10. A person skilled in the art will appreciate that a variety of other drilling devices can be used, and guidepins - In another aspect, a method for repairing ligaments can be performed using a surgical drill guide apparatus, such as the
instrument 60 ofFIG. 1 .FIG. 4 illustrates one exemplary method for forming bone tunnels for ligament grafts in a surgical procedure, and in particular dual tibial tunnels of a human knee in an arthroscopic procedure. Thefirst guide member 12 can be positioned adjacent to a bone, e.g., thetibia 100, such that thefirst guide member 12 can aim thefirst guide pin 50a through thetibia 100 along a first pathway, e.g., the firstlongitudinal axis 13a extending through thefirst guide member 12 and thefirst drill guide 40a. Positioning thefirst guide member 12 can include inserting thedistal portion 10a of theprobe arm 10 through an arthroscopic portal (although theinstrument 60 can also be used in an open procedure) and orienting it such that thedistal tip 18 of theprobe arm 10 can engage a section of atibial plateau 110 of thetibia 100 at an intended tibial tunnel exit point. Thefirst drill guide 40a can be advanced until the guide sleevedistal teeth 44 engage the cortical bone of thetibia 100 at a desired tibialtunnel entrance location 122. The drill-tippedguide pin 50a can be inserted through the center channel 41 of the firstguide pin sleeve 40a, mounted to a conventional surgical drill driver, and advanced through thetibial bone 100 using the surgical drill/driver so that thetip 51 a of thepin 50a is proximate to thetip 18 of theprobe arm 10 on thetibial plateau 110 and indicates intended tunnel depth. Thefirst guide pin 50a can be inserted through thefirst guide member 12 at any point during the procedure, but it is typically inserted after thefirst guide member 12 has been positioned at thetibia 100 and before thesecond guide member 30 has been positioned at thetibia 100. - To form a second bone tunnel, the
second guide member 30 can be positioned adjacent to thetibia 100. Positioning thesecond guide member 30 can include inserting theoutrigger arm 26 through the thru-hole 12b of thefirst guide member 12. Adjustment of the location of thesecond guide member 30 on theoutrigger arm 26 determines the relative positions of the tibial tunnel entrance points to one another, while the vertical offset of theoutrigger arm 26 determines the relative vertical offset of the tibial tunnel entrance points. A rotational position of theoutrigger arm 26 about the axis AX1 can be adjusted to orient the vertical offset between the two tibial tunnels. In this embodiment, anadditional guide pin 21 has been inserted through a thru-hole 20 in theoutrigger arm 26 at a 45° angle position on theoutrigger arm 26 to act as a position reference with respect to the tibial crest and to help correctly determine the offset. Once at a desired vertical offset, theoutrigger arm 26 can be secured in position using thethumbscrew 22. If thesecond guide member 30 is not already secured to theoutrigger arm 26, it can be secured to theoutrigger arm 26 at the desired angle A1 relative to thefirst guide member 12. Thesecond guide member 30 can be slidably moved alongoutrigger arm 26 toward and away from thefirst guide member 12 to adjust the A1 angular orientation of thesecond guide member 30 relative to thefirst guide member 12, and once positioned as desired it can be tightened and locked in position using the thumbscrew 32. Thesecond drill guide 49b and thesecond guide pin 50b can be inserted and advanced through thesecond guide member 30 as discussed above. - If desired, variations in the method of using the
instrument 60 can be employed depending upon surgeon preference. For example, theinstrument 60 can be completely assembled prior to deployment and tibial engagement, the order of drilling the tunnels may be varied, thesleeves pins - With the guide pins 50a, 50b in place in the
tibia 100, theinstrument 60 can be disengaged from thebone 100. Both of the ratchetedguide pin sleeves guide members sleeves respective guide members outrigger arm 26 can be removed from thefirst guide member 12 by releasing thethumbscrew 22 and withdrawing the still assembledoutrigger 26 and thesecond guide member 30 over theguide pin 50b. Thefirst guide member 12, along with the attachedslider arm 16 andprobe arm 10, can be withdrawn over theguide pin 50a, leaving the twoguide pins tibial bone 100 along intended tibial tunnel trajectories having respective tibial tunnel exit points 106, 108 as shown inFIG 5 . - Tibial tunnels of the desired diameter can then be drilled and reamed over
guide pin wires FIG. 5 illustrates 5mm tunnels having a 3mm offset, although any offset and any size reamers can be used.FIG. 6 shows, by way of non-limiting example, a variety of possible tunnel offset positions using either a 5mm or 8mm reamer. In an exemplary embodiment, a kit is provided containing a plurality of outrigger arms, each having a predetermined offset that corresponds to the tunnel offset positions shown inFIG. 6 . A person skilled in the art will appreciate that, while the axes of thepathways guide members - Because of the angle A1 and vertical offset between the
guide members second guide pin 50b (and hence the second tibial tunnel) can converge toward thefirst guide pin 50a (and hence the first tibial tunnel), however the axes will not intersect.FIG. 7 illustrates a cross-section ofFIG. 3 , looking toward theprobe arm 10. A distance D can separate the guide pins 50a, 50b, and the distance D can vary based on the offset of theoutrigger arm 26 and the position of thesecond guide member 30 on theoutrigger arm 26. By preventing intersection of the axes, overlap between the tunnels formed is minimized or prevented. This is advantageous as the tunnels can each maintain a substantially constant diameter through the entire length thereof, thereby ensuring that the grafts disposed therein will have sufficient freedom to move without impingement by the tunnels. While the offset and the distance D are preferably set to prevent intersection of the axes, theinstrument 60 enables a surgeon to allow intersection, such as if the offset is slight enough or is nonexistent. In such a case, it may be advisable for easier maneuverability to slightly withdraw the secondguide pin wire 50b prior to reaming the tunnel over the firstguide pin wire 50a. - The end result is first and second
tibial tunnels 120, 130 that meet with an offset at thetibial plateau 110 as shown inFIGS. 8-9 . The first andsecond tunnels 120, 130 form, respectively, first andsecond passageways 128, 138 that extend between first andsecond entrance openings - Once
tibial tunnels 120, 130 are in place, completion of a dual bundle ACL reconstruction can be performed based on individual surgeon preference. As shown inFIG. 10 , two femoral tunnels can be created in a femur 200. A currently available conventional femoral offset guide can be used through one of thetibial tunnels 120, 130 to locate a guide pin at the appropriate anatomic position within the femoral notch. A conventional cannulated acorn reamer can be used to create a femoral tunnel of the appropriate depth. A second guide pin, placed either through the second tibial tunnel 130 or an auxiliary arthroscopic portal, can be positioned adjacent to the first femoral tunnel location and a tunnel drilled to the appropriate depth in the same manner as the first. - Graft bundles can next be passed through the
tibial tunnels 120, 130 into the femoral tunnels in a conventional manner. A guide pin with an eyelet can be re-introduced through one of thetibial tunnels 120, 130 into the corresponding femoral tunnel and extended along the tunnel axis until the guide pin tip extended through the distal tissue of the lateral thigh. One of the graft bundles can be doubled over a passing suture, the suture can be threaded through the eyelet of the guide pin, and the guide pin can be pulled until the passing suture exited from the skin on the thigh. The passing suture would be used to pull the graft through thetibial tunnel 120, 130 into the femoral tunnel until appropriately seated. The second graft bundle can be passed and seated in the same manner as the first. In the case that an arthroscopic auxiliary portal was used in the creation of the second femoral tunnel, a second guide pin can be reintroduced through the auxiliary portal and an intermediate step of capturing an attached passing loop with a crochet hook or suture grasper inserted through thetibial tunnel 120, 130 and pulling the loop though the tunnel in a retrograde fashion would be required prior to proceeding with passing the second bundle of the graft in the manner described above. - Fixation of the graft in the tibial and femoral tunnels can be accomplished using any of a variety of conventional fixation methods/devices, including but not limited to interference screws, cross pins, sheaths with compression screws, and cortical buttons, posts and screws. One method for anchoring bone grafts in bone tunnels is through a "cross-pinning" technique in which a pin, screw, or rod is driven into the bone transversely to the bone tunnel so as to intersect the bone graft and thereby cross-pin the bone graft in the bone tunnel. In order to provide for proper cross-pinning of the bone graft in the bone tunnel, a drill guide is generally used. The drill guide can ensure that the transverse passage is positioned in the bone so that it will intersect the appropriate tunnel section and the bone graft. The femoral bundles of the graft can be fixed first using the chosen femoral fixation method. The knee can then be flexed to an appropriate position and the bundles can be tensioned to an appropriate amount prior to placement of the tibial fixation devices. With a dual tunnel approach, each of the graft bundles may be tensioned and fixed at different flexion positions and tension levels during the procedure.
- A person skilled in the art will appreciate that the various methods and devices disclosed herein can be formed from a variety of materials. Moreover, particular components can be implantable and in such embodiments the components can be formed from various biocompatible materials known in the art. Exemplary biocompatible materials include, by way of non-limiting example, composite plastic materials, biocompatible metals and alloys such as stainless steel, titanium, titanium alloys and cobalt-chromium alloys, and any other material that is biologically compatible and non-toxic to the human body.
- One skilled in the art will appreciate further features and advantages based on the above-described embodiments. Accordingly, the description is not to be limited by what has been particularly shown and described, except as indicated by the appended claims.
Claims (11)
- A surgical drill guide apparatus (60) for ligament repair, comprising:a first guide member (12) having a first longitudinal guide passage (13) adapted to receive a drill guide pin (50a) therein to form a bone tunnel;a first support arm (26) coupled to and extending horizontally from the first guide member, the first support arm having at least one arcuate section; anda second guide member (30) having a second longitudinal guide passage (31) adapted to receive a drill guide pin (60b) to form a bone tunnel, the second guide member being slidably disposed along the at least one arcuate section to form a variable angle (A1) relative to the first guide member,characterised in that the apparatus further comprises a second support arm (16) coupled to and extending vertically from the first guide member (12), and an engagement member (17) slidably mounted to the second support arm (16).
- The apparatus of claim 1, wherein the first support arm is fixedly mated to the first guide member.
- The apparatus of claim 1, wherein the second support arm is fixedly mated to the first guide member.
- The apparatus of claim 3, wherein the second support arm includes at least one arcuate portion.
- The apparatus of claim 3, wherein the engagement member (17) has a distal tip (18) adapted to indicate an exit location of bone tunnels formed by drill bits disposed through the first and second guide members.
- The apparatus of claim 1, wherein the first and second guide members each have a longitudinal axis (13a, 31a), and the axes do not intersect.
- The apparatus of claim 1, further comprising a first drill guide (40a) mounted in the first longitudinal guide passage and a second drill guide (40b) mounted in the second longitudinal guide passage.
- The apparatus of claim 1, wherein the second guide member includes a locking element (32) adapted to lock the second guide member in a position on the at least one arcuate section.
- The apparatus of claim 2, further comprising a plurality of markings formed on the at least one arcuate section for indicating the angle between the first and second guide members.
- The apparatus of claim 7, further comprising markings formed on the first and second drill guides and adapted to indicate a depth of a bone tunnel formed by drill bits disposed through the first and second drill guides.
- The apparatus of claim 6, wherein the first and second guide members each include a locking mechanism for locking a drill guide slidably disposed in a fixed longitudinal position.
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US7678151B2 (en) * | 2000-05-01 | 2010-03-16 | Ek Steven W | System and method for joint resurface repair |
US7163541B2 (en) | 2002-12-03 | 2007-01-16 | Arthrosurface Incorporated | Tibial resurfacing system |
US9468449B2 (en) * | 2010-12-02 | 2016-10-18 | Smith & Nephew, Inc. | Reconstructive joint tunnel drilling locator |
US7901408B2 (en) | 2002-12-03 | 2011-03-08 | Arthrosurface, Inc. | System and method for retrograde procedure |
US8388624B2 (en) * | 2003-02-24 | 2013-03-05 | Arthrosurface Incorporated | Trochlear resurfacing system and method |
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